PRESCRIPTION SEARCH REQUEST FORM - Download as DOC

							PRESCRIPTION SEARCH REQUEST FORM
This form must be completed electronically or in BLOCK CAPITALS in black ink otherwise the form will be returned to the
Authorising PCT/Hospital or Dispenser. Mandatory fields are identified by *.

If you are a PCT, Hospital or Dispenser please email the encrypted form to PrescriptionSearchRequest@ppa.nhs.uk OR
fax back to NHS Prescription Services on 0191 270 0025 with a headed cover sheet.


Requesting Organisation *.............................................................................................................................
Contact Name *………………………………………………….. Email* …………………………………… ….
Contact Telephone* ……………………………………………... Fax …………………………………….... ……
Address prescription copies to be sent to* ...……………………………………………………………………..
……………………………………………………………………………………………………………………………

Brief description of Request: * …………………………………………………………………………………….
……………………………………………………………………………………………………………………………


Dispenser account ref *……………………….
Dispenser name and address* (unless completed as part of requestor details)……….………
…………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………….
Postcode *………………………………………

Dispenser /Prescriber please provide the date of dispensing and Patient details or
Date of Dispensing and Medication*
 Presentation/Drug Name                                                       Form         Strength          Qty          Practice /           Date
                                                                              No.                                         Presc Code           Disp




Patient’s name and address …………………………………………………………………………………………
……………………………………………………………………………………………………………………………

PCT and Hospital Staff Only Please ensure you have provided the following information on your epact report:


 1. Dispenser Code     2. Month / Year     3. Form Number
 4. Prescriber Number  5. Product Details


PCT/Hospital/Dispenser Authorising Signature *…………………………………………Date *……………….



Form PS2          Version 18                               Last Published 01/03/2012                                       Page - 1 -